Editor’s note:
Recent cases involving the undertreatment of pain, the over-treatment of pain
(and thereby the creation of addicts), and whether drug seekers have any legal
rights to pain management have created management problems for the emergency
physician. This issue of ED Legal Letter will look at some of these cases.
The author addresses recent changes in pain management medications, and readers
will be able to develop a practical approach to the patient with pain with fewer
worries about the legal consequences.

Introduction

The emergency department
(ED) is the pivotal organization of a hospital, as its workings result in the
community’s impressions (reputation) and subsequent use (business) of its services.
A hospital’s reputation and business are its life’s blood; a hospital could
not exist in the competitive health care industry without positive reputation
and business.

There essentially are two
categories of patient populations that utilize emergency services:

1) People who are unable
to wait until primary care is available (when they can see a provider in a "routine"
visit). These patients either have a traumatic injury or a painful condition
that progresses to unbearable pain, or the fear that postponing their visit
would result in irreparable harm to themselves; and

2) People who seek frequent
medical attention for various conditions but have failed to identify their health
care needs with any particular physician. When patients in this category consistently
seek opioid medication for pain treatment, and concomitantly have no insurance,
they possess a characteristic often identified with drug abusers.1

As the old "gatekeeper"
concept has been eliminated by competition among various third-party payers,
the general practitioner no longer is in a position to stem the tide of using
the ED as the dumping ground for the least desirable patient type. Our chance
of eliminating the second category of ED patients seems grim indeed. Who, then,
can blame the ED practitioner for having a jaded view of pain management? This
view often is defined as a tendency to assume that all patients seeking opioids
are drug seekers because they are addicted or have a drug problem.

In all specialties of health
care, most clinicians quickly can name a patient type whose treatment either
gives them the least satisfaction or that they long to eliminate from their
practices. Every ED physician longs to eliminate the patient known as the "frequent
flyer," who frequents the ED looking for opioids.

The ED clinician’s responsibility
to treat pain is challenging. Often, the emergency practitioner is unfamiliar
with a patient’s history, personality, and character, and only sees a patient
briefly. Furthermore, the clinician must balance the need to give adequate analgesia,
rather than being so cautious that he underprescribes pain medications, with
the alternative potential of overprescribing and essentially becoming the patient’s
drug supplier.

There now are nonopioid
choices for both mild and moderate pain. They can avoid the side effects of
opioids and their potential for addiction in those patients vulnerable to it.
Yet, so many patients who frequent the ED brush off all nonopioids by saying
either, "That doesn’t work for my pain," or "I’m allergic to everything except
[his or her opiod of choice]."

There essentially are two
types of pain: around-the-clock (ATC) pain, and pain that is predictable according
to one’s activity. When pain is moderate to severe and interferes at certain
times each day with the quality of one’s life, constant dosing should be used
to treat it. Pain that can be predicted (the arthritic hand/wrist condition
that causes residual pain after grocery shopping or weeding the garden) should
be treated prophylactically with analgesia prior to the inciting activity.

Since a pain scale is inversely
proportional to plasma levels of analgesic, low plasma levels result in higher
numeric scores. This occurs routinely for patients who are prescribed too few
pills and therefore must hold out to make their pills last; when their pain
is severe, they want at least two pills and then are back in a holdout mode
until the next time they must take two pills.

These constant, yet opposite,
peaks and valleys of analgesia and pain scale scores result in unnecessary pain
and conditioning for patients. Many of these conditioned patients are created
by the clinical practice of routinely overprescribing short-acting opioids and
consistently underdosing them. For example, when a patient in family practice
presents with tennis elbow, low back pain, or sciatica, a clinician automatically
may prescribe as needed (PRN), short-acting opioids as a first-line treatment,
when nonopioids may be more effective and less harmful to many patients.

One reason for this automatic
use of opioids may be because, until relatively recently, clinicians thought
there was no other real choice for analgesia. In the past, the clinician felt
comfortable supplying patients with small numbers of pain pills, to use as they
pleased, under the erroneous perception that a few pills couldn’t harm patients.
Thus, peaks and valleys of opioid levels in plasma, rather than a constant level
just above a patient’s threshold for pain, became the norm. In the peaks came
the opioid side effects, including a sense of well-being or euphoria that, over
time, conditioned the patient to expect it or even to seek it when treating
himself for pain. Although vulnerability to addiction may only exist in 6-10%
of the general population, the other 90-94% have a potential to become conditioned
to expect euphoria with analgesia.2 In fact, the hundreds of thousands
of patients who are conditioned to seek euphoria simultaneously with analgesia
may not be addicted.

The addicted patient will
have the disease of "three C’s":

a craving for euphoria;

loss of control over
how he or she obtains euphoria (two or more physician suppliers, opioids with
alcohol or cannabis ingestion, etc.); and

negative consequences
to the quality of his or her life.

The conditioned patient,
on the other hand, will be certain that nothing but short-acting PRN opioids
will result in analgesia. Many patients who could benefit from effective analgesia
(without opioids) for mild to moderate pain (they are not conditioned) are automatically
given one to two short-acting opioids every four to six hours. This is over-prescribing.
The automatic use of short-acting opioids for PRN use often, quite simply, is
a habit for the majority of physicians because:

We just don’t think
of nonopioids for pain since, until recently, we had so few effective, safe
non-opioid analgesics to choose from; or

So many patients have
said that nonopioids are ineffective for pain (some of these patients are
routinely accustomed to experiencing a euphoric sensation when taking pain
pills). Using the PRN label but prescribing far too few pills to result in
a constant level of analgesia for ATC moderate to severe pain is underdosing.
Constant dosing, by prescribing enough pills to allow a steady state plasma
level of opioid analgesia, results in the most efficacious analgesia for ATC
pain with the least potential for harm to the patient.

Liability issues for malpractice
and/or criminal negligence plague all clinicians at every turn, whether underprescribing
to avoid scrutiny (for overprescribing) or overprescribing (to appear compliant
with mandated pain management instituted by the Joint Commission for Accreditation
of Healthcare Organizations [JCAHO] in 2001). It is a well-known fact that the
retrospective investigation of a clinician’s intent escapes exacting proof.
A clinician’s professional opinion holds much weight, yet it seems to be the
general consensus that any behavior that attracts oversight from either law
or medicine’s regulating bodies should be avoided at all costs. Shortly after
JCAHO’s mandated pain management standards began to be enforced (or scored for
accreditation), it became apparent that the threshold for investigating clinicians
who undertreated pain was high, while the threshold for investigating clinicians
who overtreated pain was low. Many clinicians subsequently saw that the solution
to liability in this realm was to consistently give only a few short-acting
opioid pills, and deny all refills (undertreat pain). Recent events now demonstrate
that the threshold for investigating prescribers who undertreat pain is beginning
to plummet. Some recent cases affirm the fact that clinicians who underprescribe
may be charged with elder abuse (criminal negligence) or medical malpractice,
or may bring on the wrath of JCAHO.

Liability for Medical
Malpractice

Estate of James v.
Hillhaven Corp.3 In 1993, prior to JCAHO mandates for pain
management, a nursing home was found liable for failing to give adequate analgesia
to a dying man whose physician had ordered PRN opioids.3 The patient,
Mr. James, was an elderly man dying in 1990 of metastatic prostate cancer of
the hip and the spine. Although his treating physician had ordered morphine
elixir (7.5 mL q 3-4 hours PRN) for pain, he died in excruciating pain. His
family was with him, and despite repeated requests for analgesia for him, no
additional doses were given. The court record indicated that a nurse had judged
the patient to be morphine-addicted. If she was concerned about the patient
dying while in her care, the doctrine of double effect should apply. That doctrine
(introduced at the time of the U.S. Supreme Court hearings on the constitutional
right to physician-assisted suicide), stated that during end-of-life care, it
is the intent of the health care provider, when practicing pain treatment, that
determines whether he or she is practicing good quality medical care and trying
to give the patient a good death, or whether he or she is practicing euthanasia
or mercy killing.4 Since the nurse in this case did not apply the
doctrine of double effect, but rather withheld pain medication, the nursing
home was found liable. This case also illustrates why PRN orders for analgesics
often should include guidelines for nursing staff (e.g., vital signs, obtundation,
pain scale, and when to consult with physician). The jury in the James
trial determined the nursing home was negligent, and returned a $15 million
award for the family. (The case eventually was settled for much less.)

Two days after discharge,
the hospice nurse noted the patient’s severe pain and tried to contact Dr. Chin,
but calls to him were not returned. Another physician succeeded in getting the
patient liquid morphine and two more fentanyl patches that greatly relieved
Mr. Bergman’s pain; he died the next day.

The adult children filed
a negligence suit against Dr. Chin for inadequate pain management. During the
trial, the standard of care correctly was given as constant dosing rather than
PRN dosing for ATC, moderate to severe pain. Under tort reform in California,
only a victim of pain and suffering can bring a medical malpractice claim against
the party or parties responsible for the pain and suffering; thus, medical malpractice
was barred for the cause-of-action in this matter. Instead, the case was brought
under civil negligence/elder abuse, and the jury returned an award to the family
of Mr. Bergman of $1.5 million.

By filing under cause of
action elder abuse, the plaintiffs had to prove a higher standard — that Dr.
Chin’s actions were reckless in not adequately addressing Mr. Bergman’s analgesic
needs (rather than the lower standard of negligent required in a medical malpractice
case). The judge at the lower court level reduced the $1.5 million amount to
$250,000 (the cap on pain and suffering if the case had been brought for medical
malpractice). On appeal in April 2002, the request for a new trial was denied,
but the judge increased the award by a factor of 1.5 (bringing the total award
to $350,000) to emphasize the importance of the case.

Liability for Elder
Abuse/Criminal Liability

A recent Michigan case
was filed when a wound care specialist was indicted for failing to prescribe
analgesia for patients on whom he routinely debrided decubitus ulcers.6
The attorney general (now governor) of Michigan, Jennifer Granholm, brought
the indictment in 2001, saying, "A physician’s oath is a sacred promise to protect
a patient, never to add to their suffering."

Liability with Licensure
Sanctions

A physician’s license was
sanctioned for failing to provide adequate analgesia in the landmark case of
Dr. Paul Bilder, a 55-year-old, board-certified pulmonologist. His license was
sanctioned for one year for a pattern of failure to provide adequate pain management
for his dying patients, who, for example, were offered only over-the-counter
medications for air hunger at the end of life.7 Dr. Bilder agreed
to have a mentor regularly work with him clinically to help him treat his patients’
pain; he also readily acknowledged his lack of training in pain management in
both medical school and residency, and took steps to fill in that gap in his
knowledge.

Liability for Manslaughter/Criminal
Liability

State of Florida
v. James S. Graves.8Criminal charges for prescribing
include diversion, racketeering, euthanasia, manslaughter, or first-degree murder.
Dr. James Graves, of Pace, FL, was indicted in July 2001 on two counts of racketeering
and two counts of manslaughter; he was convicted in a jury trial on all four
counts in July 2002.9 The prosecutor argued that Graves essentially
was running a cash-only practice that was selling drugs to all clients who wanted
them, without documentation that he knew what he or his patients wished to accomplish
toward improving the quality of the patients’ lives.

The spring 2003 Journal
of Law, Medicine, and Ethics contains several articles concerning scrutiny
and potential liability for health care professionals in regard to how they
treat pain. In one such article, the criminal prosecution of clinicians was
evaluated using two case scenarios, or hypotheticals, proposed to the chief
prosecuting officials at county levels in Connecticut, Maryland, Oregon, and
Washington.10 This study, along with another companion article,11
indicated some positive changes and identified goals for future progress on
the nation’s road to efficacious pain management with the least harm to patients
who are prescribed opioids.

The author of the first
article, Stephen J. Ziegler, a professor of political science at the University
of Washington-Pullman, found that most prosecutors did not believe that the
medical profession polices its own, yet they readily acknowledge limited experience
or proper pain management education and understanding when dealing with such
matters. It generally was agreed that the most likely culprits for diversion
of pharmaceuticals were deceptive patients, followed by a doctor’s lack of pain
management knowledge, and only infrequently by impaired or dishonest doctors.
It also generally is accepted that dosage, frequency, and duration of opioid
use alone do not constitute sufficient evidence to indicate inappropriate use.

Prosecutors further said
that important factors in whether to prosecute included: 1) whether the medical
board has investigated and handled the matter appropriately; 2) whether the
board investigated but failed to take appropriate action; and 3) whether the
doctor emphasized his own financial interests over patient care. Since one consensus
noted above was that the prosecutors felt they were out of their realm in understanding
pain management, it may be difficult for clinicians to understand how they subsequently
could discern whether medical boards had or had not handled the matter appropriately.

The two scenarios that
were used as survey hypotheticals were:

A pharmacist, recognizing
his responsibility to ensure that prescriptions for controlled substances
are for legitimate medical purposes, is asked to fill a morphine supply for
more than 30 days. He and the local police suspect the physician/prescriber
is contributing to the drug problem in the community. The police seek your
(the prosecutor’s) advice. Would you indict or investigate the clinician?

A hospice physician
summoned to the home of a dying 25-year-old AIDS patient gives repeated doses
of morphine and diazepam for air hunger and a respiratory rate of 44/minute
after furosemide failed to relieve the patient’s severe shortness of breath/anxiety;
the patient dies during this titration. Would you prosecute the physician?

Of the 83 respondents in
the study concerning the first scenario, 45.8% estimated the likelihood of recommending
police investigation at 40% or less; 43.4% estimated the likelihood of recommending
police investigation to be 60% or more. Half of the respondents claimed they
didn’t know whether an offense had been committed, and gave a 60% or greater
likelihood of referring the matter to the state medical board in lieu of investigation
or prosecution.

In the second scenario,
similar findings emerged. The article pointed out a significant opportunity
for state medical boards to take leadership roles in proper pain management
education for both the medical and legal professions. Instead of more statutes
from their end, the prosecutors would welcome better medical profession guidelines
so that clinicians could find the balance requisite in efficacious pain management.

The second article surveyed
36 medical boards and, although the survey showed a definite positive trend
towards eliminating volume or doses of opioid as reasons to investigate, it
also noted widely varying responses and states that medical boards are far more
likely to consider complaints of over-prescribing than of underprescribing.

The article calls for a
lower threshold for investigating physicians who are not doing enough to evaluate
and efficaciously treat pain in spite of a plethora of widely accepted pain
management guidelines.

Ideally, the oversight
for the medical profession should rest within the profession itself. One solution
to this need to police one’s own would be to develop a policing network that
would consist of panels of physicians in all states who have no financial or
political issues with any physician whose work they are asked to evaluate. They
could be called on to review a physician’s management of pain, for example,
if circumstances accumulated that warranted such oversight.

A Method for an Approach
to Analgesia in the ED

All clinicians about to
prescribe opioids for analgesia should be willing to ask — and determined to
have answered — the question that either law or medicine overseers might ask:
"Where are you going with this pain management plan?" As prescribing clinicians,
we have a right to an answer for that question from any patient whom we treat
for pain. Definitions for success are critical even in the short-term treatment
realm of an ED. A success definition for both functionality and a numerical
rating scale (NRS) is ideal. A chronic pain patient recently chose "to be able
to ride a bicycle with my three children" and "a 5 on the [10-point] pain scale
rather than the 7 or 9 I live with most days" as his two success definitions.
In an ED pain patient encounter, on the other hand, a success definition for
functionality should be preceded by patient education as to whether function
should be minimal (strict evaluation and rest of the injured part) or not. A
success definition for the NRS should include patient education, as well (never
promising zero pain, but striving for perhaps a 4 or lower on the pain scale).

A time frame for success
also is critical. In a chronic pain patient scenario, an agreed-upon time frame
before reevaluation may be six weeks, three months, etc. In an ED, a time frame
should include sufficient time for an elective physician follow-up (up to five
days), or until expected resolution of the pathology (as much as seven to 10
days).

As a rule, clinicians often
underestimate patients’ pain. An interesting study12 using 200 ED
patients and their 48 physicians rated patients’ pain using a VAS (visual analog
scale) both on arrival and discharge. The systematic extent of miscalibration
(physicians gave significantly lower ratings than did patients both on arrival
and discharge) was greater with expert than with novice physicians —perhaps
clinicians become conditioned to underestimate patients’ pain.

A recent study validated
the verbally administered NRS (0-10 rating scale) in the ED setting.13
This study assessed the comparability of the NRS and the VAS as measures of
acute pain in 108 ED patients at presentation, 30 minutes, and 60 minutes later.
NRS scores were correlated strongly to VAS scores at all time periods. When
educating patients about the NRS, it is important not to unintentionally demean
their pain. For example the example, "Put your hand in a blazing fire. . . .
Now you can’t take it out! . . . That’s severe pain!" often will engender anger
rather than cooperation from the patient. A better way to educate a patient
about what the NRS means might be to ask the patient to imagine that his favorite
meal is set before him; that he hasn’t eaten for more than 12 hours; and that
a patient in severe pain would not take a bite because he wouldn’t want to bite
or chew it and that he couldn’t taste it, because his entire psyche is occupied
with severe (7-10 on the scale) pain. A patient in moderate pain (5 or 6 on
the scale) would take a bite, recall its goodness, then perhaps eat no more,
as it is difficult but possible to distract this patient from pain, even for
a brief time. The patient in mild pain might well be distracted enough to eat
the entire meal and enjoy it, as it is relatively easy to distract a patient
in mild pain (1 to 4 on the scale). When a patient seems uncooperative to using
the NRS, he may be concerned that you will trivialize his pain; he must be told
that that will not be the case.

Wherever inflammation is
etiologically associated with pain, an NSAID should be prescribed; if the pain
is mild to moderate, the NSAID alone may be sufficient (especially in nonconditioned
patients). If the pain is moderate to severe and an opioid will be prescribed,
the NSAID will give synergism for analgesia and, thus, will decrease the amount
of opioid used and provide an anti-inflammatory effect. When the pain is ATC
and cannot be predicted for foreseen activity, constant dosing is the key to
both the avoidance of deleterious effects and the resultant efficacious resolution
of the underlying malady. This constant dosing is indicated not just for opioids,
but for NSAIDs, as well, since compliance, steady state levels of the agent,
and avoidance of peaks and valleys then will be achieved.

How can the ED clinician
identify and distinguish between the legitimate acute or chronic pain patient
and the patient who is either conditioned or addicted? A recent American Medical
Association monograph14 is helpful in such endeavors. Both the patient
who is conditioned and the patient who is addicted will demonstrate some of
the adverse consequences of opioid use — decreased functionality, negative affective
state, and/or intoxication. The patient who is addicted will develop compulsive
use of opioids to the detriment of his or her quality of life.

The so-called pseudoaddict
is a patient who seems to exhibit the behaviors we attribute to an addict (a
compulsion to obtain and a craving to use opioids for their euphoric rather
than their analgesic effects with resultant negative effects to the quality
of his life), but in fact is simply seeking analgesia, since he has not been
titrated to or treated adequately to an analgesic state. These patients are
wrongly labeled as having a problem with drugs, but in fact, they have a problem
with untreated pain.

The ED Approach to Pain
in Children

Children brought to the
ED in pain often are challenging to treat. Their helplessness is a source of
empathy for clinicians, their frequent inability to reason is frustrating, and
the road to analgesia for them is barred by the added factors of their fear
and anxiety. When venipunctures, painful procedures, or intravenous fluids are
required for care, local anesthetics are indicated.

A topical anesthetic must
penetrate the skin surface as well as the dermis to block the A-delta and C
fibers from pain transmission. A 4% gel of amethocaine, a derivative of tetracaine,
under an occlusive dressing for 30 minutes gives good analgesia for venipunctures;
EMLA cream (a mixture of lidocaine and prilocaine) also is used, but it has
a longer onset of action (one hour). Liposonal lidocaine (ELA-max) facilitates
transcutaneous delivery and is available as an over-the-counter medicine that
can be massaged into the skin without occlusion, providing skin anesthesia within
30 minutes. Even with its shorter application time, ELA-max gives analgesia
equivalent to EMLA.15 Acetaminophen, either orally or rectally, (at
doses of 10-15 mg/kg q 4-6 hours) gives good analgesia by blocking pain impulse
generation peripherally (in mild to moderate pain), and is an antipyretic by
way of its inhibition of cyclooxygenase in the brain, but it is not an anti-inflammatory
agent. Neonates have a slower elimination half-life, so the drug must be given
less frequently.16

Nonopioid choices for mild
to moderate pain are first line, and the NSAIDs appear to have a lower incidence
of renal and gastrointestinal effects in pediatric patients than they do in
adults.17,18 Ibuprofen in liquid form often is chosen (100 mg/tsp)
according to weight. The only parenteral NSAID presently available is ketorolac
(Toradol), and in doses of 0.8 mg/kg parenterally, it has been shown to be effective
for mild to moderate pain in the ED setting.19

An agent for severe anxiety/agitation,
such as midazolam (Versed) or diazepam (Valium), often can eliminate the need
for opioids; a child with lacerations often can have local anesthesia injected
and wounds repaired without the wait required after topicals are applied for
pre-emptive analgesia simply by giving an oral dose of midazolam. With its short-acting
and short-recovery interval, it is given orally (0.5-0.75 mg/kg) 20 minutes
prior to treatment. Overdose of this medication (respiratory depression or hypotension
in a dehydrated patient) is rare, but reversible with flumazenil (IV at 0.1
mg increments q 2 minutes), which takes effect in one to three minutes; however,
its effect may last only 30-45 minutes and the patient may become re-sedated
after the flumazenil wears off.

The use of opioids in children,
when needed for control of moderate to severe pain, is to be encouraged. A morphine
bolus of 0.05-0.1 mg/kg IV every two to four hours often is sufficient for moderate
to severe pain, and is effective in five minutes with up to three hours’ duration.
An alternative is IV hydromorphone (0.02 mg every two to four hours). Since
IV boluses are effective but their duration of action is short, continuous infusions
can be used to circumvent fluctuations in plasma concentrations and give a more
prolonged analgesia. Continuous infusion of morphine (0.02-0.03 mg/kg/hr, or
hydromorphone (0.006 mg/kg/hr) would be indicated for more prolonged analgesia
(during and after procedures, etc.).20

Pain Management in the
ED Adult Patient

The approach to pain management
for the adult ED patient in each pain category (severe, moderate, or mild) should
be different.

Severe: A patient
with severe pain cannot be distracted sufficiently even to get a helpful history
or physical. He is the patient "on all fours" (renolithiasis, active peristalsis
against a mechanical gastrointestinal (GI) obstruction, multiple trauma victim
who is mentally alert with stable vital signs, etc.). Such a patient needs emergent
analgesia, most often using opioids, with their peak plasma level about six
minutes after IV administration. Although titration with analgesia is a consideration,
it is best to give each IV dose time to take effect (5-10 min.) rather than
to give too much and end up with an obtunded patient unable to cooperate with
his diagnostic work-up.

When ED patients get analgesia
prior to a diagnostic work-up (the essence of which is the physical exam), the
more common opinion is that such analgesia will not compromise the diagnosis
but will, rather, affect a more humane route to the most efficacious care. Certainly
in acute abdomen pathology, the patient’s physical exam must be adjusted (as
to the clinician’s technique) after the analgesia, perhaps by applying slightly
more manual pressure; this can be done readily and is acceptable to the majority
of surgeons or other clinicians who will resume a patient’s care after ED work-up
and preliminary care. A recent convincing study conducted in the department
of emergency services at Massachusetts General Hospital looked at the effects
of morphine analgesia on diagnostic accuracy in abdominal pain.21
Although only 74 patients were enrolled in this study, it is the largest study
to date on this topic. Patients were randomized to placebo or IV morphine sulfate.
Diagnostic impression and physical examination findings were collected before
and after a period of drug titration to a maximum of 15 mg morphine sulfate
over 60 minutes. The physicians’ diagnoses at the end of the titration period
were clinical (prior to imaging results). Diagnostic accuracy did not differ
between the groups (64.2% vs. 66.7%). There were no instances of opioid administration
masking physical examination findings.

The choice of opioid should
have full agonist properties at the mu receptor; the two most commonly used
in the ED setting are IV morphine and hydromorphone. Morphine is cheap, effective
in five minutes (at doses of 0.1-0.2 mg/kg), and lasts two to three hours.

Hydromorphone, five to
eight times more potent than morphine, is effective in one minute, lasts a shorter
time than morphine, but does not accumulate in the presence of renal failure,
making it a better choice for patients with renal insufficiency. At doses of
0.01 mg/kg q 5 min., it often is better tolerated when morphine causes irritability,
hallucinations, or disorientation. Fentanyl, 60-80 times more potent than morphine,
with its short onset (1-2 minutes) and duration (20-30 minutes), at a dose of
0.0005 mg/kg q 5 min. is another choice. Etomidate with similar short onset
and duration also is well suited for a short burst of analgesia for reductions
(e.g., of fractures or dislocations); however, these latter two choices are
more expensive.

Unfortunately, the frequent
use of meperidine in many EDs, despite JCAHO’s exhortation to minimize its use,
continues. The active metabolite of meperidine, normeperidine, with its prolonged
half-life of 15-20 hours in patients with normal renal failure (longer half-life
in patients with renal insufficiency), and its cerebral toxicity with accumulation22
may not be a concern in the ED, but it should be for two reasons:

In the report of a
recent case of ED use of meperidine for a 55-year-old woman with a history
of sphincter of Oddi dysfunction, mild renal insufficiency (creatinine 0.6
mg/dL) and mild liver insufficiency (aspartate aminotransferase of 56 U/L
and alanine aminotransferase of 34 U/L), escalating doses of the opioid were
begun in the ED and continued after hospital admission.23 On day
four of admission, the accumulated meperidine dose was 2125 mg, with adverse
consequences to the patient; and,

Besides its potential
for cerebral toxicity, meperidine has marked euphoric properties. Although
it is tempting to the ED clinician to use it IM, it contributes heavily to
conditioning patients to expect and demand euphoria for the pain that brings
them to the ED. In the ED treatment of migraines, for instance, when meperidine
often is given, opioids are not first-line treatment at all (NSAIDs followed
by triptans are recommended24), yet the migraine patient requesting/demanding
Demerol (meperidine) is the very frequent flyer who often is the cause of
ED clinicians’ frustrations.

One plan to minimize Demerol
use would be to declare a future date that would mark the end of meperidine’s
use for urgent care pain management, and a written announcement made available
to all frequent flyers; this announcement would be given to patients seen in
the ED who are deemed to be frequent fliers, and would offer them a chance to
attend educational sessions on pain control (which include information about
conditioning and the deleterious side effects of meperidine) prior to the date
after which meperidine will no longer be available.

Moderate: A patient
with moderate pain will rate his pain on the NRS a 5-6. He may or may not require
analgesia prior to obtaining a history and physical. Distraction from his pain
periodically during a history and physical simply may result from his ardent
desire to cooperate fully with the evaluating clinician. On the other hand,
he may require analgesia for various reasons, including frustration or anger
about past ED experiences, or from present personal issues unrelated to his
illness.

If an ED patient in moderate
pain requires analgesia prior to the history and physical, it often can be given
orally, since lab results, including x-rays, often will not be available for
the 45 minutes it takes for the analgesia to reach steady state plasma levels
for analgesia, at which time a thorough history and physical can be obtained.
One could argue that until the history and physical are done, the lab studies
needed are not yet determined; in the real world, unfortunately or not, in most
busy EDs it is routine to get preliminary lab work based on the patient’s chief
complaint or the precursory history alone.

The choices in prescription
oral analgesia for patients with moderate pain are an NSAID, propoxyphene (Darvon),
tramadol (Ultram), or an opioid (e.g., codeine or hydrocodone [Vicodin]). Propoxyphene,
a drug of dubious distinction,25 and meperidine (Demerol) are the
two most euphoric opioids available. The accumulation of propoxyphene in the
plasma, if given every six hours routinely, will allow the patient to "step
up" to analgesia after six to nine doses (or after 24-48 hours), but the euphoria
is experienced about 45 minutes after the first dose.

If NSAIDs are to be given,
there are good reasons to consider the COX-2 inhibitors, not just because they
are safer,26 but also because preliminary studies show that they
result in both analgesia and in anti-inflammation. Recent studies have thrown
doubt onto ibuprofen’s synergism for analgesia when combined with opioids in
patients undergoing total hip surgery,27 but the COX-2 inhibitors
clearly have shown a 40% reduction in postoperative opioid use when concomitantly
used for that same post-operation patient type.28 In this study,
patients are given a placebo or valdecoxib (Bextra), at 20 mg or 40 mg one to
three hours before hip replacement, and then q 12 hours thereafter for 36 hours
post-operation. All patients were given morphine via patient-controlled analgesia
(PCA) pump post-operation, and the amount of morphine used in each group was
recorded. The amount of PCA morphine was decreased by either 43% (valdecoxib
40 mg group) or 41% (valdecoxib 20 mg group) compared to the placebo group.
In addition, the study showed that the patients getting 43% or 41% less morphine
were more satisfied with their pain management, because they had less grogginess,
nausea, confusion, etc.

Mild: A recent study
showed that most patients (45 out of 60) presenting with painful conditions
to an urban ED had not taken any medication for pain relief prior to their ED
visit. The reasons (16 in all) for this were varied, and were not always because
the patient "did not think about it." The three most common reasons were: 1)
"I don’t like taking tablets" 2) "I ran out of tablets" and 3) "The pain wasn’t
bad enough." When patients have mild pain, rating 1-4 on the NRS, analgesia
recommendations either can be prescribed or suggested (if over-the-counter)
on discharge, when the patient is given discharge instructions. For example,
a patient with a seemingly infected wound may feel that delay of medical attention
will result in irreversible harm to himself, so he presents to the ED rather
than waiting until the following day when care may be less expensive.29
His pain, however, may be mild; and on discharge from the ED, he will be instructed
to constant-dose his antibiotic, but that for best pain control he should use
strict elevation and rest of the affected body part in addition to constant
dosing one 500 mg acetaminophen tablet every four hours (for a total of 3 g/day).

If prescribed analgesics
are utilized, the choices are NSAIDs, other nonopioids, and opioids. If NSAIDs
are prescribed in the ED setting, in view of both a lack of follow-up and, often,
of compliance, we should use as safe a product as possible for any given patient
(or document that the patient had education concerning both nonselective and
specific COX-2 inhibitors, emphasizing the importance of vigilance or cumulative
effects).

In 1997, a total of 113,000
patients were admitted to hospitals for complications of nonselective NSAIDs
(from melena with hypotension to hematochezia or hematemesis), and 16,000 of
those patients died from gastrointestinal bleeding. A review of these patients’
histories showed that 60% of them had no pre-emptive symptoms prior to the complicating
event that brought them to the ED.30 The COX-2 inhibitors clearly
have shown less gastrointestinal toxicity than the nonselective class of NSAIDs;31
they should be constant dosed for acute pain to obtain their maximum ATC analgesic
and anti-inflammatory effects.

If short-acting opioids
are chosen for analgesia, the best approach for dosing instructions should be
associated with whether the pain will be ATC or present only with certain activity
(e.g., with physical therapy/physical activity ordered as an outpatient). A
patient who will be assigned physical therapy should be told that the level
of pain medication in his plasma when he gets to physical therapy has a great
role to play in his rehabilitation. If ATC is presumed, then constant dose the
medication every four hours either just during waking hours (if a supine and
comfortable position at night allows the patient to sleep without awakening
in pain), or during all hours of each day and night (if the pain is present
and interferes with sleep, the patient should set an alarm for three to four
hours after going to bed; and when the alarm goes off, he should take another
pill and go back to sleep). The patient should be instructed to avoid taking
two pain pills at a time, to avoid the sudden rise in opioids and the resultant
peak of opioid and possible side effects, including euphoric sensations.

If nonopioids are chosen,
tramadol (Ultram) and its acetaminophen combination (Ultracet) are commonly
used examples. Being neither an opioid nor an NSAID, tramadol has centrally
acting activity as a weak mu opioid agonist and as an inhibitor of reuptake
of both serotonin and norepinephrine. An important consideration when prescribing
tramadol is that since it lowers seizure threshold, it is contraindicated for
patients with a seizure disorder, head trauma history, or for patients on selective
serotonin reuptake inhibitors or opioids.

The ceiling effect for
combination medications often does not have to do with the central ingredient,
but rather with whatever is combined with the central ingredient. Tramadol/acetaminophen,
with its 37.5 mg of tramadol and 325 mg of acetaminophen (rather then the 500
mg in many hydrocodone products), is considered safer than hydrocodone/acetaminophen.
Two tablets of tramadol/acetaminophen q 6 hours (the maximum recommended) would
result in 2.6 g acetaminophen per day, whereas two tablets of hydro-codone/acetaminophen
every four hours (the maximum recommended) results in 6 g acetaminophen each
day. The addiction or conditioning properties of tramadol now are being recognized,
and thus, exceeding dosage recommendations should be avoided.

Summary

When probable cause exists,
oversight bodies —whether in medicine or law — have a right to ask clinicians
the same question: Did we know where we (and thus the patient) were going with
our patients when treating their pain? Did we have a plan to improve their functionality
and, thus, their quality of life? The only proof of intent we have to offer
in answering their question is to show documentation of our definitions for
success and our follow-up evaluations of the patients that show progress toward
these definitions.

As pain management education
becomes more widespread,32 law and medical oversight bodies will
be able to make guidelines more definitive, since the objectives of both law
and medicine will then coincide.

ED clinicians have the
potential of impacting pain management in a very critical way. By refusing to
supply patients with pain medications for their own use, they can begin to offer
efficacious pain treatment using a structured plan that will result in less
frustration for themselves and less deleterious effects on patients from the
medications they choose.